Innovations in mesh kit technology for vaginal wall prolapse - OBG ...

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Innovations in mesh kit technology for vaginal wall prolapse Hydrodissection aids in reducing complications. FIGURE 2 The Elevate Anterior and Apical Prolapse Repair System Components of the Elevate Anterior and Apical Prolapse Repair System, including fixating arms, apical and anterior needles, adjustment tool, eyelet applicator, and mesh. Issues of mesh placement DR DAVILA: How does a surgeon obtain the best mesh placement and reduce the risk of complications? DR BERCIK: To reduce complications, the mesh must be inserted in the proper plane. Hydrodissection—the injection of saline, dilute lidocaine with or without epinephrine, or another local anesthetic into the vesicovaginal space—can aid in doing this. 3 The other thing we need to stop, which we were taught traditionally, is to limit any trimming of excess vaginal tissue. DR CLARK: I believe that it is important to encourage patients to take either oral or vaginal estrogen preoperatively to minimize the risk of exposure. Of course, you may have to overcome patients’ fears and ensure that the patients are appropriate candidates for estrogen use. I also administer a single dose of a second- or third-generation cephalosporin one hour before surgery. S4 January 2010 / Supplement to OBG Management Most patients with uterine prolapse do not need a hysterectomy. By eliminating the hysterectomy, you have decreased operative time and lowered mesh complications. Appreciating the advantages of a new mesh kit DR DAVILA: Can you describe the benefits of the Elevate® Anterior and Apical Prolapse Repair System (FIGURE 2) (American Medical Systems, Inc. [AMS], Minnetonka, MN) procedure? DR BERCIK: A key advantage is that Elevate uses small polypropylene fixation tips to affix the mesh to the sacrospinous ligament (FIGURES 3A AND 3B). These tips leave a very small “footprint,” preventing them from passing through the ligament and/or into the posterior area. We can access the sacrospinous ligament without going through or behind it, both of which would increase the risk of neurovascular injury.
FIGURE 3A Apical needle: Protective sheath The depth-limiting feature of the Elevate apical needle allows advancement of about 12 mm of the self-fixating tip into the body of the ligament. In this illustration, the self-fixating tip is retracted. Additionally, Elevate does not utilize external needle passages. The interior fixation arms anchor into the sacrospinous ligament, avoiding the external pulley effect that we have seen with other devices like the Capio, which could put constant tension on key structures, including the obturator internus muscle and the sacrospinous ligament. Elevate provides direct fixation into the supporting structures without that pulley effect, which may translate into less pain. DR MOORE: I agree that avoiding external needle passages is a key advantage of the Elevate system. Some of the past complications we’ve seen with mesh kits seem to be secondary to the mesh arms penetrating through the levator muscles. With any of the transobturator kit procedures, if an arm is placed too tight, then there can be some banding and tension that can cause pain or discomfort on a generalized basis or with intercourse. DR CLARK: For me the major advantage of the Elevate over the prior trocar-based mesh kits is the comprehensive anterior and apical support combined with the lighter density mesh. FIGURE 3B Fixation tip deployment The self-fixating tip is deployed for correct placement. How to use the new support system DR DAVILA: Can you discuss the specific procedural aspects of this new approach? DR BERCIK: I make a midline incision, no larger than 4 cm, starting at the bladder neck and extending down toward the apex vertically. This allows me to establish the plane and access the fixationpoint landmarks. After making the deep dissection, sweeping the bladder off of the vagina to the apex and developing the paravaginal space, I reach the ischial spine and sacrospinous ligament bilaterally. Then I measure the anterior-to-posterior distance. After the dissection, I place lightweight absorbable monofilament sutures through the apex, or cervix if the uterus is being preserved, and another stitch midline at the bladder neck to hold the graft in place. I usually use 2 or 3 stitches proximally and 1 stitch distally. The sutures are held until the mesh is introduced, at which time they are secured to the implant. Avoiding external needle passages is a key advantage of the Elevate system. www.obgmanagement.com Supplement to OBG Management / January 2010 S5
Page 1 and 2: AVAILABLE AT WWW.OBGMANAGEMENT.COM
Page 3: Traditional use of the sacrospinous
Page 7 and 8: Managing more advanced prolapse DR

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